Be aware that patients now are more informed and may have a Do Not Attempt Resusitation order (DNAR). Many times EMS is called to help family deal with the dying process and resusitation should not be attempted. This is an end of life issue, not a life saving issue.
If this is not the case, proceed:
*Person Collapses (Adult, assume cardiac arrest)
*Assess Responsiveness (Shake and Shout or if trauma, Touch and Talk
to pt) "Are you awake?"
*Activate emergency response system (call 911 or if in a medical setting
call a code blue or call for a defibrillator) - the main rhythm
associated with cardiac arrest in an adult is V.fib/Pulseless V. Tach
and NEEDS to be shocked as soon as possible to survive.
Begin the Primary Survey
A=Airway, Open and assess airway. Use head tilt-chin lift or if trauma suspected jaw thrust method to open the airway. Look (for chest rise), listen (over the mouth for air movement), and feel (for breathing against our face). Treat occasional gasps as if not breathing. The new guidelines recommend that if in the field and ALONE (one person), open all airways by head tilt-chin lift. The rationale is that one person doing a jaw thrust will need to stay and maintain that head positioning. It is more of a priority to open the airway and breath for the patient than it is to maintain the head in proper alignment.
B=Breathing, take 5-10 seconds to check for breathing. If none, give 2 slow breaths over 1 second and enough to cause visible chest rise. If the first does not go in, reposition the head (reopen the airway) and try again.
C=Circulation, Assess pulse and skin color and movement from pt for signs of circulation. If no carotid pulse within 10 seconds, start Chest Compressions hard (1 1/2 to 2 inches) and fast (100 compressions per minute). (Give 30 chest compressions for every 2 breaths for two minutes, then switch). If there is a pulse, still rescue breathe for the pt 10-12 times per minute, give a breath enough to cause chest rise and complete recoil.
Helps Arrives
D=Defibrillation, Attach to a defibrillator-monitor or with paddles do a quick look for a shockable rhythm. We are looking for V.fib or V.Tach to defibrilate. There will be no rhythm (a straight line) in this case or no QRS complexes present. This is Asystole. Do not shock asystole.
Begin Secondary Survey
A=Airway, Insert oral airway, use a bag-valve-mask with 100% oxygen to ventilate (12-15 times per minute) the patient while equipment is being prepared for intubation.
B=Breathing, Confirm and secure the tube with an approved airway device and ventilate the patient with 100% oxygen (12-15 times per minute).
C=Circulation, Reassess circulation resume CPR, Note: Asynchronous chest compression may now be done with ETTube placement. Place IV, antecubital vein is the first choice or Intraosseous access and run IVFs if appropriate - Normal Saline or Lactated Ringers are the preferred choices.
**Confirm asystole in a second lead and make sure all your leads are attached to the patient and the monitor. This is done to check for a fine V.Fib in another lead and to treat the patient, not the monitor if a lead is loose or disconnected.**
Transcutaneous Pacing is not in the new recommendations.
Give:
Epinephrine 1 mg IV q 3-5 minutes
OR
Vasopressin 40 Units IV, one time dose or after 1st or 2nd dose of Epinephrine. (wait 10-20 minutes before starting epinephrine)
Atropine 1mg IV q 3-5 minutes for 3 doses.
Flush with 20mL NS or run IVFs to keep meds running into the vein and raise the arm. After giving the drug, then resume CPR for 30 - 60 seconds to help circulate the medication, remember the only heartbeat is the one your manually give the patient.
D=Differential Diagnosis, Search for and treat reversible causes including but not limited to 5 Hs and 5 Ts:
Hypovolemia-give fluids and/or blood products (the #1 cause of PEA), Hypoxia-give 100% ventilated oxygen,
Hypo/hyperkalemia(low or high K level)-give KCL boluses for low K+ level/-give NaHCO3 1mEq/kg IV q 10 minutes for high K+ level,
Hydrogen Ion (acidosis)-hyperventilate pt or give NaHCO3 depending upon lab values,
Hypothermia/Hyperthermia-warm pt with blankets and warmed IVFs for hypothermia. Keep the patient from getting too warm.
Thrombosis Pulmonary (PE)-thrombolytics or surgery to remove the blockage,Thrombosis Cardiac (MI)-thrombolytics or surgery to remove the blockage, Tension Pneumothorax-needle decompression,
Cardiac Tamponade-paracardial centesis,
Tablets (OD)-give NaHCO3 for certain antidepressants.
Trauma - treat the underlying problems such as source of bleeding, surgical needs, respiratory support, electrolyte imbalances, etc.
See PEA algorithm for a detailed explanation of each.
Consider terminating efforts
